MEDICARE: KENFIELD WALTERS INTL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	4101005991	MI
2	261QM0850X	Adult Mental Health Clinic/Center	6301006592	MI

General Provider Information

NPI Number	:	1134550510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENFIELD WALTERS INTL LLC

Provider Business Mailing Address
First Line	:	38864 COUNTRY CIR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-1025
Country	:	US
Telephone Number	:	248-737-0388
Fax Number	:	248-254-3890

Provider Business Practice Location Address
First Line	:	38864 COUNTRY CIR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-1025
Country	:	US
Telephone Number	:	248-737-0388
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. JUDITH CHRISTINA WALTERS
Credential	:	PH.D.
Telephone Number	:	248-737-0388

Provider Enumeration Date	:	12/10/2013
Last Update Date	:	12/10/2013

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